Provider Demographics
NPI:1417984717
Name:BETHEL, BRIAN L (PCC LCDCIII)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:BETHEL
Suffix:
Gender:M
Credentials:PCC LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 STATE ROUTE 159
Mailing Address - Street 2:PO BOX 6179
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-6179
Mailing Address - Country:US
Mailing Address - Phone:740-775-1260
Mailing Address - Fax:740-773-1264
Practice Address - Street 1:4449 STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-6179
Practice Address - Country:US
Practice Address - Phone:740-775-1260
Practice Address - Fax:740-773-1264
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE4376101Y00000X, 101YP2500X
OH991594101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000315699OtherANTHEM